Examining the governance and structure of the global health financing system using network analyses

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Abstract Background Development assistance for health (DAH) has been a vital in achieving the improvements in health since the year 2000. This was facilitated through the distribution of financial and in-kind resources, valued at over $37 billion in 2017, from a group of global health and development entities to low- and middle-income countries. The resources from these organisations originated from a variety of sources, including national treasuries, philanthropic foundations, and private corporations. The allocation of these resources are also governance arrangements, in many cases with disease and intervention priorities determined outside the recipient localities. Methods The structure of global health financing was investigated using network analyses of DAH actors in the context of disease/health area-specific funding. The dataset utilised in the analyses, assembled by the Institute of Health Metrics and Evaluation, consisted of 27 years of annual estimates (1990-2017) of DAH flows tracked from sources through channels to 177 recipient countries, disaggregated by health area. Results The number and diversity of organisations involved in global health financing saw a rapid expansion since 1990. The most prominent structural changes were the recession of large multi-laterals and the emergence of non-OECD and private entities. Amongst these, unofficial partnerships were detected. This study identified several weaknesses in the global health financing system pertaining to specific diseases as well as child and maternal health. Conclusions To provide sustainable, efficient, and effective health intervention implementation in DAH-recipient countries, it is important to understand the structure of the global health funding system. These results will be used to develop potential future financing scenarios, and to understand the impact of the global health financing structural characteristics on the improvement of targeted health outcomes in developing countries. Key messages Global health financing has undergone substantial structural changes since 1990, with multi-laterals scaling back proportionally and the emergence new types of entities. The governance and delivery arrangements within global health are linked to the financial arrangements, potentially causing structural weaknesses that threaten the sustainability of the system.